'Ruth goes home' is the account of a woman with terminal
bowel cancer who found that donated breastmilk helped her gain the
strength to travel home. Ruth's experience raises questions about
how human milk might have been beneficial. Those questions are addressed
later in the paper but first, Helen Gardner tells Ruth's story in
an extract from the book Snapshots from our lives.

I met Ruth through the B'nai B'rith* Environment Group
(BBEG). She was an American who came here [Melbourne, Australia] with
her husband and had been here for about 6 years when we first met. I
first learned that she had cancer in late 2002 when I picked her up to
go to a meeting. I thought she looked very thin and drawn. When I asked
her just as a routine question how she was, she made some remark about
feeling the cold very badly because of the chemotherapy. She wanted to
go home.

I saw her intermittently in 2003, and in early June I received an
email saying chemo had ceased to be effective, and that she was going
back to the States for further treatment within 4 weeks. She had planned
a potlatch to give away her goods before they left, but on the day the
hostess was not there. She had been admitted to Cabrini Hospital the day
before.

The next I heard, she was leaving on 8 August and there was to be a
farewell party for her on 3 August, but once again, on the day the guest
of honour was not there. She was back in Cabrini. She looked bad. Eating
was painful and took a long time to ease. Her doctor had given her 2
weeks to live if she stayed in Australia. I thought she was dying, and
so did she. She told me she did not think she was going to make it to
catch the plane.

The day before she was due to leave I went to say goodbye. Her
bowel blockage had eased and she looked a little better. She was
determined to get on that plane the next day, and was busy investigating
things she could eat and drink which would enable her to stay hydrated
during the trip. One of her visitors suggested breast milk, and another,
a nursing mother, provided some to try. It was an instant success. Ruth
made arrangements to leave the hospital by 8 am next morning and
arranged for a wheelchair to be waiting at the airport. And so the quest
began. Where to get Ruth enough breast milk to get her through the trip?

Some members of the Australian Breastfeeding Association (ABA) were
contacted informally [see ABA policy next page], but the majority of
contacts came through a young friend of mine, 37 weeks pregnant herself
at that time, who is very involved with the ABA and who got on the phone
immediately. I contacted my daughter who was also nursing, and she
contacted a couple of friends. By 8 pm that evening I was out on
'the milk run' through Oakleigh, Glen Iris, North Fitzroy and
Fairfield, aiming to deliver enough milk that evening for the planned 8
am start the next morning.

Meanwhile, Ruth's doctor, confronted with her determination to
leave, decided she was not well enough to take an ordinary flight, but
that he could arrange for a 'medical evacuation, meaning that she
would travel on a stretcher with a drip, an oxygen supply, and a doctor
and nurse in attendance. This was expected to take 5 to 7 days to
organise, and our initial plans to collect enough milk to last Ruth for
the flight were transformed into collecting enough milk to keep her
alive for a week or so, plus enough frozen milk to last a few days once
she arrived home.

This we did!

My young friend and her mother concentrated on collecting in the
Kew/ Ivanhoe region. With magnificent help from Hatzolah** and other
friends in the orthodox community, I focused on Caulfield. With
contributions coming in from many people who had heard about the need,
we collected over 12 litres of milk, (fresh and frozen)--a magnificent
effort. A prayer group was also initiated by those connected with
Hatzolah.

Ruth improved remarkably on the breast milk. Her digestive system
was able to utilise the milk, and within a few days she was able to eat
small amounts of baby rice cereal and stewed apple. By 13 August she was
off the drip and sitting out of bed for short periods. By the time she
flew home on 16 August, she no longer needed a stretcher and was able to
travel first class, using the lay-back seats as a bed. During the
stopover in Los Angeles she visited with an aunt and uncle and a very
good friend.

It took about 25 hours from the time of leaving Cabrini to arrival
at the hospital in the city where her mother lives. The flight was
trouble free. Ruth arrived in far better condition than we had ever
hoped for. After a short stay in hospice care she went home to her
mother, who had offered to look after her. She died peacefully 15 days
after returning home.

Saving Ruth's life was never part of the plan, although we
probably all hoped that we could. We set out to get her home to see her
family, and achieving that was a little miracle in which we all took
part, and which could not have happened without the combined efforts of
all of us.

For my part, this experience, while somewhat bizarre, was
wonderfully rewarding. The outpouring of care, concern and prayer for a
stranger was deeply touching. Ruth was several times in tears as she
expressed her gratitude to the many people whose milk was keeping her
alive. If we blessed Ruth with the gift of going home, she blessed us
with the opportunity to reach beyond ourselves, to join with others,
many unknown, and to experience goodness in the world. In the end, we
offered Ruth far more than milk, and she offered us the rare mitzvah***
of caring for another without thought of return.

Before Ruth began drinking breastmilk she was receiving fluids in
an intravenous drip. Obviously Ruth needed hydration and nutrition, but
eating was painful. After a few days of taking breastmilk, she was able
to have her intravenous line removed and to eat small amounts of
semi-solid food. She must have been well enough hydrated and nourished
to manage without parenteral nutrition. Ruth attributed her improvement
to the breastmilk. How could breastmilk achieve that, if other foods did
not? There have been no controlled studies of human milk's effects
in adults with cancer, but breastmilk is well known to affect infant
health. Breastmilk has anti-inflammatory and antioxidant properties as
well as providing species-appropriate nutrition. Some breastmilk
components have been identified as being able to kill cancer cells
without affecting healthy cells. Perhaps some of these properties might
be useful to cancer patients, as well as to infants? What follows is
unavoidably speculative and limited to generalities. It aims only to
illustrate the biological plausibility of breastmilk's use as a
complement to conventional medical treatments.

Breastmilk is easily digestible

Breastmilk has an osmolality similar to that of serum, that is, the
concentration of dissolved salts and glucose (osmotically active
solutes) is similar to that of serum. This means the dissolved nutrients
and water from breastmilk can easily cross the gut wall and do not draw
water into the gut. Iso-osmolality is one of the features that makes
breastmilk suitable for people with damaged gut lining, such as that
which occurs after chemotherapy. However, if lactose is not digested in
the small intestine because gut damage (or normal ageing) has reduced
the amount of lactase present, it may be digested by bacteria in the
lower bowel and draw water into the lower bowel causing discomfort and
diarrhoea. Given that Ruth's story does not record any such
distressing symptoms, she was probably able to digest the lactose.

Human milk fats are particularly suitable for digestion and
absorption (Innis 2011). This is important in infants since they have
less efficient fat absorption than adults, but it may also be valuable
to a person with cancer. Glucose tolerance can be impaired in cancer
patients, so the European Society for Clinical Nutrition and Metabolism
(ESPEN) guidelines suggest 'lipids might be the preferred
substrate' for cancer patients (Arends et al 2006). Studies
comparing infant absorption of different fats have shown that human
infants absorb fats very efficiently from breastmilk Triglycerides
consist of a glycerol backbone with three fatty acid chains extending
from the backbone. In the process of digestion, lipase removes the two
outer fatty acids, leaving the central fatty acid still attached to the
glycerol backbone. Studies comparing infant absorption of different fats
have shown that human infants absorb long chain fats and calcium more
efficiently with that arrangement (Carnielli et al 1996). Early formulas
had a tendency to form calcium soaps in the infant gut, resulting in
hard stools because the fats were not efficiently absorbed (Innis 2011).
The damaged gut, post chemotherapy, might also benefit from human
milk's arrangement of fatty acids Breastmilk proteins provide a
balanced source of amino acids and many have bioactivity in the gut:
antibacterial activity (lactoferrin, lysozyme); mineral binding
(lactoferrin, alpha-lactalbumin); and enhancement of vitamin absorption
(haptocorrin, folate binding protein) (Lonnerdal 2010). These factors
and the presence in breastmilk of digestive enzymes such as lipase,
would be expected to maximise the absorption of breastmilk nutrients.
Breastmilk contains bile salt-stimulated lipase which may begin the
process of digestion of the milk fats (Lonnerdal 2010; Innis 2011).
Chemotherapy kills not only cancer cells, but any actively reproducing
cells in the body and the cells lining the gut are included So after
chemotherapy, it could be expected that Ruth may have had reduced
production of digestive enzymes due to gut damage. The lipase in the
donated breastmilk may have compensated for that. Breastmilk also
provides amylase which may have helped digest the rice cereal and stewed
apple Ruth was able to eat after a few days.

Breastmilk would not provide adequate levels of protein to maintain
body weight in an adult unless unrealistic volumes were consumed, but
towards the end of life for a cancer patient, maintaining normal protein
nutrition becomes less important than maintaining hydration (Arends et
al 2006).

It has been shown in infants that breastfeeding ameliorates the
anorexia that can follow immunological challenge such as mild illness or
vaccination (Lopez-Alarcon et al 2002). After a vaccination breastfed
infants showed no decrease in milk intake, in contrast to
artificially-fed infants. Artificially-fed infants are also more likely
to develop fever after a vaccination than breastfed infants--an
indication that breastmilk's anti-inflammatory properties function
at the whole person level, at least in the presence of a mild stimulus
(Pisacane et al 2010).

A person suffering from loss of appetite can readily be 'put
off' by strong tastes and smells of food. Among a study of cancer
patients taking pasteurised human milk some found the taste awful and
had to mask it. Some took raw milk and described it as 'delicious,
sweet and lively' (Rough et al 2009). Ruth was given unpasteurised
milk. The taste was acceptable and drinking was probably easier than
eating for her, since chemotherapy often decreases saliva production and
makes swallowing solid food difficult.

Antioxidants in breastmilk

In cancer patients, signs of oxidative stress are raised and
antioxidants are at low levels (Arends et al 2006). Breastmilk provides
a number of recognised antioxidants and breastfed infants show evidence
of more effective antioxidant systems than artificially-fed infants
(Friel et al 2002; Shoji et al 2004). Breastmilk's antioxidant
systems might be useful to a person with cancer. The pathogenesis of
cancer-related anorexia/ cachexia syndrome (CACS) is not yet fully
understood, but it seems to be multifactorial and involve both
inflammatory and oxidative stress (Laviano et al 2007). The weight loss
and muscle loss that accompanies CACS is not resolved by simply
increasing nutrient supply (Mantovani et al 2010). A trial of agents
described as 'mildly effective' when given singly was recently
found to be effective at relieving cancer-related anorexia/ cachexia
syndrome when given in combination. The researchers proposed the
combination in the expectation that the multifactorial CACS would be
better addressed by multiple treatments (Mantovani et al 2010).
Accordingly while breastmilk's supply of digestible nutrition was
likely to be important to Ruth's improvement, it is not enough to
completely explain it. Breastmilk's mix of anti-inflammatory and
antioxidant components may have been effective in alleviating
Ruth's anorexia.

Anticancer components in breastmilk

Reports of components in breastmilk that have the capacity to kill
cancer cells in vitro have given some patients the hope that breastmilk
might help them. Rough and others (2009) reported a study of 10 cancer
patients' experiences using human milk. Most of the patients
reported feeling some benefit, such as an increase in appetite or less
nausea during chemotherapy. However, the study did not use any objective
measure of improvement in the patients' health.

Human Alpha-lactalbumin Made LEthal to Tumour cells (HAMLET) is a
protein-fatty acid complex derived from human milk, which kills cancer
cells Synthetic HAMLET has been shown to reduce papillomas and bladder
cancer when applied directly HAMLET is formed in the laboratory at low
pH from [alpha]-lactalbumin and oleic acid which are both present in
human milk, though the HAMLET complex is not. Researchers have
speculated that HAMLET may form in the infant's stomach and this
might contribute to the difference in incidence of cancer between
breastfed and artificially-fed infants (Mok et al 2007). (Breastfed
infants have a lower incidence of acute myelogenous leukaemia and acute
lymphocytic leukaemia than artificially-fed infants [Ip et al 2007]).

TNF-Related Apoptosis-Inducing Ligand (TRAIL) is another component
of human milk that is able to kill cancer cells. TRAIL binds to
'death receptors' on the surface of cancer cells and sets off
the process of cell death or apoptosis. It is not entirely clear why
TRAIL doesn't kill normal cells, but possibly normal cells have
many decoy receptors that compete with the active death receptors for
binding to TRAIL. TRAIL has other functions too and may be involved in
promoting cell differentiation in the gut lining Researchers are
investigating ways to use TRAIL in cancer treatments (Stolfi, Pallone
& Montelone 2012; Allen & El-Deiry 2012). TRAIL has been found
in human milk at levels 100 times those in serum (Davanzo et al 2012).

However, Ruth's cancer was advanced by the time she was given
breastmilk and it could not be expected that the anticancer activities
in breastmilk would have had much impact on the tumour.

Immune components in breastmilk

It is well known that breastfed infants have lower rates of
infection than artificially-fed infants. Breastmilk contains numerous
immunologically active components. Antibodies are probably the best
known immune component of breastmilk. Lactoferrin has antibacterial and
antiviral properties, lysozyme has antibacterial functions, partially
digested [alpha]-lactalbumin fragments have prebiotic functions and
bactericidal functions (Lonnerdal 2010). Oligosaccharides are found in
human milk in a greater variety than in other milks and at high
concentrations--up to 15g/L (Kuntz, Rudloff & Kunz 2008).
Oligosaccharides act as decoys to some pathogens: they bind specific
microbes in the gut and in that way prevent the microbes from binding to
and penetrating the gut wall. Oligosaccharides are also prebiotics,
providing nutrition to particular probiotic bifidobacteria and so
helping establish a healthy gut flora (Bode 2 009). The lactating breast
can be considered a part of the mucosal immune system and produces
antimicrobial peptides that are secreted into breastmilk (Murakami et al
2005). The immune components in breastmilk support the infant's
developing immune system Chemotherapy increases the cancer
patient's risk of infection by damaging the patient's immune
system and the immune system of breastmilk could be expected to
ameliorate that effect.

The use of breastmilk in adults

Donated milk has been provided to sick children and adults with
apparent benefit. Arnold has reported several instances when human milk
was the only food tolerated by sick infants, children or adults and
other instances where it appeared to influence improvement in colitis or
gastro-oesophageal reflux in an adult (Arnold 1996; Arnold 1995a +b;
Wiggins & Arnold 1998).

Human milk was used to provide a source of IgA for two
IgA-deficient liver transplant recipients. Their infection-free recovery
period was significant because liver transplant in IgA-deficient
individuals is associated with high rates of mortality, largely due to
post-surgical infections (Merhav et al 1995).

CONCLUSION

Human milk is an easily digested, antioxidant, anti-inflammatory,
anti-infectious food. The same factors that make it suitable for the
immature gut of the human infant may be useful to an adult with a
damaged or inflamed gut. It is unlikely that breastmilk will ever be
available in such quantities that it could serve as a complementary
medicine, but for those who want to use it and have donors willing to
provide some, it may be a useful adjunct to conventional medical
treatment.

Ruth's story is as much about human generosity as it is about
human milk. Ruth's last weeks were warmed by the gift she was given
and, in reflecting on that gift, I am reminded that in every case
breastfeeding is more than providing nutrition. Donation makes the
'gift' aspect of breastmilk obvious and a mother breastfeeding
her own child is also giving more than food. Even while considering the
physiology of human milk it is good to remember that giving human milk
is fundamentally about human relationships.

'Ruth goes home' was written by Helen Gardner and first
published by Hybrid Publishers in Snapshots from our lives Reproduced
with permission.

Extract from the Australian Breastfeeding Association's Human
Donor Milk Policy

* The Association does not facilitate informal milk sharing by
linking private donors and recipients.

* The Association accepts no responsibility for expressed
breastmilk donated by its members ABA members who donate expressed
breastmilk do so as breastfeeding mothers, and not on behalf of the
Association.

* The Australian Breastfeeding Association may provide information
about donor milk resources, including links on the Association website,
to human milk banks and other resources as a service to the community
and to assist parents to make an informed decision. The Association does
not necessarily endorse the information available from these resources
and makes no representations as to their accuracy.